Abstract
We report two elderly patients with putaminal hemorrhage possibly related to multiple angiographically occult intracranial vascular malformations (AOIVM) which were verified only with high-field magnetic resonance imaging (MRI).
Case 1. A 77-year-old woman was admitted to the hospital because of sudden onset of left hemiparesis on Day 2. Computed tomography (CT) exhibited a hyperdense area in the right putamen compatible with hypertensive putaminal hemorrhage, although she did not have a clear history or evidence of hypertension. Cerebral angiography demonstrated no abnormality.High-field MRI operating at 1.5 Tesla, however, revealed multiple small low intensity areas, combined with high-or isointensity signals, scattered in putamens, thalami, white matters, cerebellum of both sides and pons. Four months later she developed another intracerebral hematoma adjacent to the previous hematoma, although her blood pressure remained normal.
Case 2. A 66-year-old normotensive woman developed a massive hemorrhage in the right putamen. She did not have any possible cause of cerebral hemorrhage such as hypertension, hemorrhagic diathesis, etc. Cerebral angiogram showed a mass sign but no vascular abnormalities. MRI demonstrated multiple small low intensities with or without high-intensity spots in addition to a hematoma.
MRI findings of these patients were compatible with those of AOIVM reported in the literature. Although AOIVM has been diagnosed clinically with high-field MRI since 1986, it is not documented that multiple AOIVMs may cause ganglionic hematoma in the elderly patients. The present cases indicate that we should be aware of the presence of AOIVM as a cause of deep-seated cerebral hemorrhage even in the elderly. Clinical implications of AOIVM may be changed if patients with cerebral hemorrhage are more carefully investigated with high-field MRI.
